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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> t�'�L.�1•'• 201 E_Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 81/2 x 11 inches in size. 84Crrne44- CZ?, 500 <br /> • See reverse side for instructions for completing this application State Sanitary Perm i;Nu'mber <br /> The information you provide may be used by other government agency programs El Check it re Iswn to previ / aaJppl�tion <br /> IPrivacy Law,s. 15.04(1)(m)I. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 1 ;2- t,?-$ <br /> Property Owner Name Propert Location <br /> Ve;,1 S(,�1 is � 1 i4,S (q T3-7 <br /> N, R ( +^co <br /> Property Owner's Mailing Address Lot Number Block Number <br /> kk Ldti.e_ <br /> City,State- jj r Zip Code Phone Number �'/` Subdivision Name or CSM Number <br /> 1'Q if "Cj (CJ+ O (7 ) -Z63 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cit Nearest Road <br /> ❑ Vil age / // P f <br /> Cj Public 1 or 2 FamilyDwelling-No.of bedrooms Town Or (r4 [ 1/1 1 l D lel <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo bJ y — 1519 0o- (wpb <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) <br /> A) 1. ler New 2_ ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> System _ ____System ___ _______ TankOnly ___ _______ Existing System __ Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ❑Seepage Bed 21Mound 30 E]Specify Type 41 ❑Holding Tank <br /> 12 E]Seepage Trench 22❑�In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area -4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> 3 a C) SSU a p Feet .Z eet <br /> Capact VII. FORMATION in gallons Total #of Manufacturer's Name Prefab Con- Steel Fiber- Plastic Exper <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank r Holding Tank I 17S-0 ( wTe -e ® ❑ ❑ ❑ I ❑ ❑ <br /> I t Pum Ta k/Siphon Chamber x Sn 1 e s ® ❑ ❑ ❑ ❑ ❑ <br /> ESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plum er's Name:(Pant) Plu tier's Signature(N tamps) MP/MPRSW No.: Business Phone Number: <br /> e(S o'ev :L�� Z1.7ZZ lir $�6-�bo� <br /> Plumber's Address(Street,City,State,Zp Cod w r <br /> /C_. f& 1/r, iY91 V�- <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includesGroundwaler ate Issue Issuing A e ignature( S ps) <br /> p <br /> pproved F1 Owner Given Initial QQ &jasurcharge fee) <br /> Adverse Determination lUd` 1 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> �OS/g4) DISTRIBUTION: Original to Cnura y,One ropy To: safety&RuilJings Diw_wn,Owner,Plumber <br />